Fifteen months after the state switched its Medicaid insurance program for more than 42,000 low-income seniors and disabled residents from a fee-for-service model to a managed care one, advocates say two firms hired to administer the program have improved services and beefed up provider networks.

But some point to cases involving patients who have seen cuts in care or who have struggled to navigate the Mainland-based plans because of language barriers or other reasons as continued areas of concern.

New statistics on the Quest Expanded Access program illustrate that mixed bag. The numbers show both insurance companies — 'Ohana Health Plan and Evercare — have decreased the average processing time for claims, from a high of 22 days to about 10, and increased the number of participating specialists.

Complaints from providers have also dropped, while complaints from Evercare members have increased. Evercare got just one complaint from a provider in April, and 'Ohana got two, down from 122 complaints against Evercare and 19 complaints against 'Ohana in the second quarter of 2009.

Meanwhile, 54 Evercare members made complaints last month and eight 'Ohana members did, according to figures provided to the Department of Human Services. In the second quarter of last year, shortly after the plans started, five Evercare members and 51 'Ohana members filed complaints.

Call volume at both plans remains high, but state officials point out that not all those calls are about problems. Some are questions about coverage. In the first quarter of last year, the plans got nearly 23,000 calls from members or providers. That compares with about 15,000 calls to the two plans in April alone.

The plans launched coverage in the Islands in February 2009, as part of a state push to improve Medicaid care, curb costs and streamline the health care system for the state's most vulnerable residents. 'Ohana and Evercare manage all aspects of care for Medicaid clients, from linking them to a doctor and coordinating their care to covering medical claims and providing transportation to appointments.

The plans have a three-year contract with the state. Of the $500 million annually that goes to Quest Expanded Access, $165 million comes from state coffers and the rest comes from the federal government.

"We believe things are going much better than at the beginning," said Patti Bazin, state health care services branch administrator, who helps oversee the Quest Expanded Access program. Last week, Bazin acknowledged that the switch to managed care was fraught with confusion, worries about coverage and concerns among clients and doctors over whether the plans had enough participating specialists.

The changes have also been challenged in court, but have so far been upheld.

"I really do have to say it's significantly improved," Bazin said. "It is meeting the needs of our clients."

CUTS IN SERVICES

Not everyone agrees. Some advocates, doctors and patients still aren't convinced the change to managed care was an improvement, and some are certain that it wasn't.

"It would be fine the way it is, if they really did what they promised," said Dr. Ritabelle Fernandes, who sees low-income patients at Kokua Kalihi Valley and Kalihi-Palama Health Center. "They're not doing what they're supposed to do."

Fernandes said her case managers spend hours on the phone with call centers at the plans to try to figure out what's covered and what's not and where patients can go for specialty care. She also said that many of her clients don't speak English and have trouble understanding their medical rights. A number of her patients, she said, are seeing cuts in care — to things like nursing or health aide services at home — but haven't filed complaints because they're afraid of losing their insurance altogether if they do.

Since the plans took over, patients have filed 209 appeals to cuts in services, claim denials or other changes, according to the state. Providers have filed 298 appeals. Details on the appeals weren't released.

For their part, the plans say they have addressed many concerns — bolstering their list of providers and specialists and working more swiftly to process claims. The plans also say that some of the problems cited by advocates aren't their fault, but a function of the inherently complex health care system, where about 65 percent of Hawai'i residents on Medicaid also have Medicare coverage for those over 65.

Figuring out whether Medicare or Medicaid covers treatment costs can be tough, even for providers.

That confusion is to blame for a significant portion of claim denials, the state says, adding that all medically necessary treatments must be approved. The 'Ohana plan denies about 21 percent of claims on average, while Evercare denies about 3 percent, according to state figures. DHS officials point out that the denial rate for the two plans is far lower than the 26 percent under the old fee-for-service model.

Erhardt Preitauer, regional president of 'Ohana, which covers more than 22,000 Quest Expanded Access clients in the Islands, said the dual insurance coverage (with clients in Medicare and Medicaid) "has caused confusion." He added, "we have spent a lot of time educating members on this."

He also said, in a statement, "We approve all medically necessary care to members."

An Evercare spokesman said the plan is "required to ... assure that members receive medically necessary services." He also said that in evaluating whether home or community-based services, such as skilled nursing home care, are needed, "we use clinical evaluation and assessment tools, input from the member, the member's providers, caregivers and family (and) our clinical field service coordinator."

One key criticism of the two insurers early on was that members, especially those on the Neighbor Islands or rural O'ahu, couldn't get access to specialists. Advocates say those problems still exist, though the plans' provider network has grown. Part of the issue is the shortage of specialists statewide, but many specialists have also opted not to participate in the program or have decided not to take new clients.

Dr. Ricardo Custodio, medical director at Wai'anae Coast Comprehensive Health Center, said the provider network in the plans "has gotten a little better. But it's not where we feel that it's to the benefit of the patients." He said wait times to see some specialists still appear longer than they should be.

Evercare launched with about 1,110 specialists, and now has 1,811.

'Ohana had 990 specialists in February 2009, and now has 1,348.

Leolinda Parlin, director of Hilopa'a Family to Family Health Information Center, which is an ombudsman for Quest Expanded Access clients, said there has been "tremendous progress" in the plans since their launch. She said her office has also been getting far fewer complaint calls from members.

"People have a better understanding of what QExA is about," she said.

In February 2009, the center got about 664 calls. In February of this year, it got 71.